What is the Health Insurance Claim Process?

Rajesh Sharma has just returned home after getting admitted to a private hospital for covid treatment. His wife was also infected but was discharged within a few days after her condition improved. Rajesh had taken a health insurance cover for the family from an insurer with the best health claim settlement ratio. He was guiding his wife from the hospital on the medical insurance claim procedure and advised her to contact the health insurance provider to get more details. Being the first time, Mrs. Rajesh found it very difficult to gather all the required information. However, after her husband returned home, he helped her with all the necessities to successfully submit their health insurance reimbursement claim.

The policyholder files a health insurance claim for the reimbursement of expenses incurred on his or her medical treatment. A wide range of services is covered under a health insurance plan, including hospitalization costs, prescription medicines, physiotherapy, OPD expenses, surgical expenses, post-hospitalization expenses, etc. During these pandemic times, it is essential for you to know about the claim settlement process in health insurance, so you are prepared if the need arises.

Types of Health Insurance Claims

With a health insurance policy in hand, knowing about the health insurance claim process is mandatory. In the healthcare claims processing workflow, you need to know about the two types of claim settlements: Cashless claims and Reimbursement claims.

• Cashless Claims
• Reimbursement Claims

Cashless Claim: As the name itself suggests, there is no need to pay for the medical treatment at the time of admission. The policyholder can avail treatment from any of the network hospitals of the health insurance provider by producing the cashless health card issued by the insurer at the hospital’s insurance desk. The expenses towards treatment and hospitalization shall be paid directly to the hospital by the insurer. In this process, a policyholder is not required to pay any amount to the hospital, as the entire cashless health insurance claim procedure is verified and approved within 4 hours.

Cashless Claim Procedure: Once you have decided to get admitted to a hospital for medical treatment, you need to follow the below steps for availing of the cashless facility.

• Select a hospital from the network of hospitals provided by your health insurance company. You may choose based on the mediclaim claim settlement ratio for faster claim approvals and fewer headaches.
• Inform about your intention to get admitted to the third-party administrator (TPA) at least before 3 days by quoting your membership number and hospital name.
• Submit the cashless claim request form at the hospital along with relevant medical reports.
• After inspection of details, you will get the status of approval within a few hours.

Once approved, the hospital bills shall be settled directly with the hospital. If your cashless request is disapproved due to specific reasons, you may seek to get your bills reimbursed after discharge.

Reimbursement Claim: The mediclaim reimbursement process is simple and similar to cashless claims, the only difference being the timeline of getting your claims. The reimbursement of medical expenses by the insurer after your treatment at any hospital is classified as a reimbursement claim. But the policyholder should pay the hospital for the treatment and then file for reimbursement claim to the TPA or insurer with all the necessary bills and medical records. After verification of the submitted documents, the reimbursement claim is processed, and either the total amount or a specific percentage is credited to the policyholder’s bank account.

Reimbursement Claim Procedure: A reimbursement claim is usually filed when the policyholder undergoes treatment at a hospital that does not feature in the network list of the insurer. The following steps will help you in that process:

• Before getting discharged from the hospital, pay all the bills
• Make sure to collect all the expense bills, prescriptions, discharge summaries, medical reports, and other relevant documents from the hospital.
• Contact the insurance company or TPA and quote your membership ID number.
• Fill the reimbursement form with correct details and attach the requested documents with it.

After verification of the submitted details, the insurer shall reimburse the medical expenses by way of a cheque or direct credit to your bank account. It is necessary to note that the reimbursement process must start within seven to fifteen days of the patient’s discharge, depending on the terms of the TPA or insurer.

Making sure your claim is not rejected

 When filing for a claim request, there are chances of it getting rejected for various reasons. Here are a few tips that will ensure your claims get approved without any hassles.

• Do not forget to research the claim settlement ratio of health insurance companies while choosing to buy an appropriate policy. A high CSR denotes the insurer to have a high claim settlement rate, whereas a low CSR means the claim rejection rate is high. Therefore, it is recommended to pick a policy with high health claim settlement ratio. After buying the health insurance policy, please read the policy documents carefully to understand all about its features, inclusions, exclusions, waiting period, and claim procedure.
• Remember to file the claim request within 7 days of discharge from the hospital.
• Make sure to collect all the documents relevant to your treatment from the hospital without fail. Not attaching a few bills to the claim form might also lead to your claim getting disapproved.

Getting a health insurance policy is a need of the hour, not only for yourself but also for your family members, with a renewed emphasis on health and hygiene. What is equally important is the need to choose the right policy with a track record of settling claims. Although the health insurance policy claim settlement ratio is a helpful parameter to judge the quality of service offered by that insurer, it is not the only factor. For quick claim settlement, you also need to understand the process and follow it meticulously, in the correct form, in order to make your cashless or reimbursement claims processed fast.